Impact of an interdisciplinary goals of care program on hospital outcomes at a comprehensive cancer center during the COVID-19 pandemic: A propensity score analysis.
Authors: David Hui, Nico Nortje, Marina C. George, Kaycee Wilson, Diana L. Urbauer, Caitlin Lenz, Susannah Kish Wallace, Clark Andersen, Tito R. Mendoza, Sajid Haque, Sairah Ahmed, Marvin Delgado Guay, Shalini Dalal, Nisha Rathi, Akhila Sunkepally Reddy, Jennifer Leigh McQuade, Christopher Flowers, Peter W. T. Pisters, Eduardo Bruera
Journal: Journal of Clinical Oncology (2022)

6502 Background: Many hospitals have established goals-of-care (GOC) programs in response to the COVID-19 pandemic; however, few have reported their outcomes. MD Anderson Cancer Center launched a multicomponent interdisciplinary GOC (myGOC) program in March 2020 that involved risk stratification, team huddles to discuss care planning, oncologist-initiated GOC discussions, communication training, palliative care involvement, rapid-response GOC team deployment, and daily monitoring with immediate feedback. We examined the impact of this myGOC program among medical inpatients. Methods: This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at MD Anderson Cancer Center, Texas during an 8-month pre-implementation (May 1, 2019 to December 31, 2019) and post-implementation period (May 1, 2020 to December 31, 2020). The primary outcome was intensive care unit (ICU) mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of patients with in-hospital do-not-resuscitate (DNR) orders, medical power of attorney (MPOA), living will (LW) and out-of-hospital DNR (OOHDNR). Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment (SOFA) Score. With a sample size of 600 ICU patients over each time period and a baseline ICU mortality of 28%, we had 80% power to detect a 5% reduction in mortality using a two-tailed test at 5% significance level. Results: This study involved 12,941 hospitalized patients with cancer (Pre n = 6,977; Post n = 5,964) including 1365 ICU admissions (Pre n = 727; Post n = 638). After myGOC initiation, we observed a significant reduction in ICU mortality (28.2% vs. 21.9%; change -6.3%, 95% CI -9.6, -3.1; P = 0.0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI -2.0, -0.7 days; P &lt; 0.0001) and in-hospital mortality (7% vs. 6.1%, mean change -0.9%, 95% CI -1.5%, -0.3%; P = 0.004). The proportion of hospitalized patients with an in-hospital DNR order increased significantly from 14.7% to 19.6% after implementation (odds ratio [OR] 1.4, 95% CI 1.3, 1.5; P &lt; 0.0001) and DNR was established earlier (mean difference -3.0 d, 95% CI -3.9 d, -2.1 d; P &lt; 0.0001). OOHDNR (OR 1.3, 95% CI 1.1, 1.6, P &lt; 0.0007) also increased post-implementation but not MPOA and LW. MPOA, LW and OOHDNR were documented significantly earlier relative to the index hospitalization in the post-implementation period (P &lt; 0.005 for all). Conclusions: This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent GOC intervention. Our findings may have implications for GOC programs during the pandemic and beyond.